Deborah Mindry

“I May Not Say We Really Have a Method, It Is Gambling Work”: Knowledge and Acceptability of Safer Conception Methods Among Providers and HIV Clients in Uganda

In this qualitative study, researchers assessed knowledge, acceptability, and feasibility of safer conception methods (SCM; timed unprotected intercourse [TUI], manual self-insemination, and sperm washing) among various health care providers (n = 33) and 48 HIV clients with recent or current childbearing intentions in Uganda. While several clients and providers had heard of SCM (especially TUI), few fully understood how to use the methods. All provider types expressed a desire to incorporate SCM into their practice; however, this will require training and counseling protocols, sensitization to overcome cultural norms that pose obstacles to these methods, and partner engagement (particularly by men) in safer conception counseling.

Factors associated with desire for children among HIV-infected women and men: a quantitative and qualitative analysis from Malawi and implications for the delivery of safer conception counseling.

Improved health outcomes have resulted in people with HIV facing decisions about childbearing. We sought to understand the factors associated with desire for a child among men and women in Malawi. HIV-infected men and women ages 18–40 were invited to participate in a brief interview about fertility desires. Single variable logistic regression was used to evaluate the factors associated with the outcome of fertility desire. Additionally, multiple logistic regression was used to assess the relationship of all the factors together on the outcome of fertility desire. In-depth interviews with women were performed to understand experiences with reproductive health care. A total of 202 brief interviews were completed with 75 men (37.1%) and 127 women (62.9%), with 103 (51.0%) of respondents desiring a child. Being in a relationship (OR: 3.48, 95% CI: 1.58–7.65, p = 0.002) and duration of HIV more than two years (OR: 2.00, 95% CI: 1.08–3.67, p = 0.03) were associated with increased odds of desire for a child. Age 36–40 years (OR: 0.64, 95% CI: 0.46–0.90, p = 0.009) and having a living child (OR: 0.24, 95% CI: 0.07–0.84, p = 0.03) were associated with decreased odds of desire for a child. Seventy percent of women (n = 19 of 27 respondents) completing semistructured interviews who responded to the question about decision-making reported that their male partners made decisions about children, while the remainder reported the decision was collaborative (n = 8, 30%). Eighty-six percent of women (n = 36 of 42 respondents) reported no discussion or a discouraging discussion with a provider about having children. HIV-infected women and men in Malawi maintain a desire to have children. Interventions are needed to integrate safer conception into HIV care, to improve male participation in safer conception counseling, and to empower providers to help patients make decisions about reproduction free of discrimination and coercion.

Challenges with couples, serodiscordance and HIV disclosure: healthcare provider perspectives on delivering safer conception services for HIV-affected couples, South Africa

Introduction Safer conception interventions should ideally involve both members of an HIV‐affected couple. With serodiscordant couples, healthcare providers will need to manage periconception risk behaviour as well tailor safer conception strategies according to available resources and the HIV status of each partner. Prior to widespread implementation of safer conception services, it is crucial to better understand provider perspectives regarding provision of care since they will be pivotal to the successful delivery of safer conception. This paper reports on findings from a qualitative study exploring the viewpoints and experiences of doctors, nurses, and lay counsellors on safer conception care in a rural and in an urban setting in Durban, South Africa.

“Our Hands Are Tied Up”: Current State of Safer Conception Services Suggests the Need for an Integrated Care Model

We conducted in-depth interviews with a variety of health care providers (n = 33) in Uganda to identify current services that could support and act as barriers to the provision of safer conception counseling (SCC). Consistent with their training and expertise, providers of all types reported provision of services for people living with a diagnosis of HIV or AIDS who desire a child. Important barriers, including a lack of service integration, poor communication between stakeholders, and the absence of policy guidelines, were identified. Drawing on these data, we propose a model of integrated care that includes both SCC services and prevention of unplanned pregnancies.

Provider attitudes about childbearing and knowledge of safer conception at two HIV clinics in Malawi

BackgroundThere is limited understanding of health care providers’ attitudes towards HIV-infected individuals’ reproductive choices, as well as knowledge about safer conception. Our study objective was to explore provider-level factors that serve as barriers and/or facilitators to the provision of reproductive and safer conception services for men and women living with HIV.MethodsTwenty-five providers were interviewed in four focus group discussions about their attitudes regarding childbearing by HIV-infected clients, reproductive health and HIV knowledge, and views and knowledge of safer conception.ResultsProviders reported ambivalence about supporting childbearing among their clients with HIV. They raised concerns about HIV-infected individuals having children, and in certain cases expressed judgment that people with HIV should not have children because of these concerns. Providers lack specific knowledge about safer conception strategies and have low level of knowledge of reproductive health, the efficacy of PMTCT, and the risks of pregnancy for HIV-infected women.ConclusionsProviders in our setting have complex attitudes about HIV-infected clients having children and lack knowledge to appropriately counsel clients about reproductive health and safer conception. Our findings highlight need for further research in this area as well as the need for provider training in reproductive health and safer conception.

Engendering care: HIV, humanitarian assistance in Africa and the reproduction of gender stereotypes

This paper draws upon recent research in Durban, South Africa to unravel the complexities of care ethics in the context of humanitarian aid. It investigates how the gendering of care shapes the provision of aid in the context of the HIV in Africa constructing an image of ‘virile’ and ‘violent’ African masculinity. Humanitarian organisations construct imagined relations of caring, invoking notions of a shared humanity as informing the imperative to facilitate change. This paper draws on varied examples of research and NGO activity to illustrate how these relations of care are strongly gendered. Humanitarian interventions that invoke universalising conceptions of need could instead draw on feminist care ethics that seeks to balance rights, justice and care in ways that attend to the webs of relationships through which specific lived realities are shaped. Essentialising feminised discourses on care result in a skewed analysis of international crises that invariably construct women (and children) as victims in need of care, which at best ignore the lived experiences of men and, at worst, cast men as virile and violent vectors of disease and social disorder.

Safer Conception Methods and Counseling: Psychometric Evaluation of New Measures of Attitudes and Beliefs Among HIV Clients and Providers.

With data from 400 HIV clients with fertility intentions and 57 HIV providers in Uganda, we evaluated the psychometrics of new client and provider scales measuring constructs related to safer conception methods (SCM) and safer conception counselling (SCC). Several forms of validity (i.e., content, face, and construct validity) were examined using standard methods including exploratory and confirmatory factor analysis. Internal consistency was established using Cronbach’s alpha correlation coefficient. The final scales consisted of measures of attitudes towards use of SCM and delivery of SCC, including measures of self-efficacy and motivation to use SCM, and perceived community stigma towards childbearing. Most client and all provider measures had moderate to high internal consistency (alphas 0.60–0.94), most had convergent validity (associations with other SCM or SCC-related measures), and client measures had divergent validity (poor associations with depression). These findings establish preliminary psychometric properties of these scales and should facilitate future studies of SCM and SCC.

Client and provider knowledge and views on safer conception for people living with HIV (PLHIV)

OBJECTIVE(S) The childbearing needs of people living with HIV (PLHIV) and the experiences of healthcare providers serving them are explored. We examine provider and client knowledge and views on safer conception methods. METHODS The study uses exploratory qualitative research to understand provider and client perspectives on childbearing and safer conception. Interviews were conducted at 3 sites (1 rural, 2 urban) in eThekwini District, KwaZulu-Natal, South Africa between May 2011 and August 2012, including in-depth interviews with 43 PLHIV, 2 focus group discussions and 12 in-depth interviews with providers. RESULTS Clients had little knowledge and providers had limited knowledge of safer conception methods. While clients were eager to receive counseling on safer conception, providers had some hesitations but were eager to receive training in delivering safer conception services. Clients and providers noted that biological parentage is a major concern of PLHIV. Clients were willing to use any of the described methods to have biological children but some expressed concerns about potential risks associated with timed unprotected intercourse. Male clients required access to reproductive health information. CONCLUSIONS Providers need to routinely initiate discussions with clients about childbearing intentions. Providers need to be enabled with approved guidelines and training to support client access to safer conception methods.

Stigma gets in my way: Factors affecting client-provider communication regarding childbearing among people living with HIV in Uganda

Introduction Many HIV-affected couples living in sub-Saharan Africa desire to have children, but few quantitative studies have examined support for their childbearing needs. Our study explored client-provider communication about childbearing and safer conception among HIV clients in Uganda. Methods 400 Ugandan HIV clients in committed relationships and with intentions to conceive were surveyed. Knowledge, attitudes and practices related to childbearing, and use of safer conception methods were assessed, including communication with providers about childbearing needs, the correlates of which were examined with bivariate statistics and logistic multivariate analysis. Results 75% of the sample was female; 61% were on antiretroviral therapy; and 61% had HIV-negative or unknown status partners. Nearly all (98%) reported the desire to discuss childbearing intentions with their HIV provider; however, only 44% reported such discussions, the minority (28%) of which was initiated by the provider. Issues discussed with HIV providers included: HIV transmission risk to partner (30%), HIV transmission risk to child (30%), and how to prevent transmission to the child (27%); only 8% discussed safer conception methods. Regression analysis showed that those who had communicated with providers about childbearing were more likely to have been diagnosed with HIV for a longer period [OR (95% CI) = 1.09 (1.03, 1.15)], while greater internalized childbearing stigma was associated with lower odds of this communication [OR (95% CI) = 0.70 (0.49, 0.99)], after controlling for all bivariate correlates and basic demographics. Conclusions Communication between HIV clients and providers about childbearing needs is poor and associated with stigma. Innovations to mitigate stigma among clients as well as training to improve health worker communication and skills related to safer conception counseling is needed.

Knowing Client Rights and Meeting Their Needs: Provider Knowledge and Attitudes Toward Meeting the Reproductive Needs and Rights of People Living with HIV in South Africa

With the widespread availability of antiretroviral treatment (ART), men and women living with HIV are living longer and healthier lives. Many of these men and women are of reproductive age and are having children or expressing the desire for children. Prevention of mother-to-child transmission (PMTCT) care has focused on preventing HIV transmission to children. A critical next step is addressing horizontal transmission between partners during conception. Providers face many challenges in the delivery of care to PLHIV which is further complicated by the call to address their reproductive needs. Despite the call to integrate HIV and reproductive health services the integration of such services faces many challenges, still falling far short of meeting the reproductive rights and needs of clients. We conducted focus group and in-depth qualitative interviews with 25 health care providers in a rural and urban ARV clinic in KwaZulu-Natal. We found that health care providers struggled to balance their perceptions of client reproductive rights and their personal attitudes and professional experiences in addressing these needs. Furthermore, despite the publication of national guidelines for safer conception, health care providers still have limited knowledge or training in safer conception strategies for PLHIV. This chapter highlights provider ambivalence in knowing and meeting reproductive rights and needs of PLHIV.